LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

March 04, 2018

When Skim Milk Masquerades as Cream

Researchers at the University of
Michigan surveyed just over 2000 people between the ages of 50 and 80 to find
out whether they thought physicians prescribe too much, too little, or just the
right amount. What they found is surprising.

Contemporary wisdom holds that
physicians are aware that they order unnecessary tests, recommend too many
procedures, and prescribe too many medications. They behave this
way, practicing “low value medicine,” in large measure because this is what
patients demand. Respecting autonomy, physicians argue, compels them to accede to
patients’ wishes—together with the fear of malpractice suits. The new study
suggests both that many patients are aware that their physicians over-treat them and that they don’t want those unnecessary treatments. Fully one quarter of those
surveyed said their own physicians over-treat, and double that number said that
physicians in general over-treat. One in six said within the last year, their doctor had advised them to have a test
or take a drug that was unnecessary. But half of those admitted to doing what
they were told to do. By contrast, just under ten percent of those surveyed
said their physician had declined to order a test or medicine that the patients
felt was indicated.

We already had fairly good evidence
that the fear of lawsuits was greatly over-stated: if physicians explain why
they don’t believe a test or drug to be warranted and document the conversation,
the chance of being sued for failing to order whatever it was that they didn’t
recommend is very slim. Now
we have fairly good evidence that it isn’t patient pressure that is influencing
physician behavior. The “Choosing Wisely” campaign, which encourages physicians
to talk to patients about why the patients shouldn’t be requesting various
tests, has it backwards.

Physicians
need to look in the mirror and recognize that we are the problem. We need to
stop arguing to ourselves that it’s better to be safe than sorry or that more
is better than less. Even relatively non-invasive tests have risks and even
moderately inexpensive medications have costs. The older the patient and the
greater the number of co-morbid conditions, the more likely a test is to have
side effects. And even the small ticket items add up when they are performed
very often. “Low value” care isn’t really low value; it’s just bad medicine.